Dr. Robert Moore III

I thought that after finishing my surgical residency there was a magical place I could call where someone would take care of all the ‘money stuff’ so I could do my ‘doctor stuff’. All that hard work and school was about to pay off – I get to help patients all day and then go home to to spend time with my family every night….

Hopefully that got a few laughs from the healthcare crowd. For everyone else, especially patients, physicians are as frustrated and unpleased with the financial side of medicine as you are (if not more). But until the system finds an easier, better way to finance patient care, complaining does no one any good.

What many people do not know is that any health insurance plan is in reality a relationship between the insurance company and the patient. Contractually, it it the patient’s responsibility to reimburse the physician. But like most businesses, customer service in a highly competitive market becomes a high priority and standard over time. And it should. Not because I love capitalism and competition that both drive better quality in this country, but because our heads are in this part of the business all day.

The short version is that every private practice physician learns the billing process and everything about healthcare insurance quickly or the light bill does not get paid nor does food make it into their refrigerators. So making sure that your patients are well informed about their clinic visit, labs, surgery, or follow up care is a top priority. This is a win-win-win for all since both patients and physicians really want to get right down to treating the problem(s). The good news is that many insurance plans are leveraging IT to make this easier for the staff to have financial answers for patients before they come to the clinic. The not so good news is that the plans have an infinite variety of payment paradigms as well as many treatment and medical devices (DME) requiring authorization by phone. Sometimes my staff can be on the phone for over 45 minutes for one patient’s custom orthotics authorization or faxing short term disability requests for surgery week after week.

Just recently we have had a complaint about pricing, EOBs, and one patients ‘sticker shock’ for both clinic treatments and surgical procedure / surgery center quotes. It’s not uncommon and we understand that these complaints come with the territory, but in reality we are all following the insurance company’s contract agreements.

Unknown to some patients is that physicians have to follow a rule where we cannot change our charges for office visits or treatments (CPT codes). And, each insurance company has individual contracts with each physician paying them different amounts for each CPT code. Hence, the customary EOB (Estimation of benefits) patients receive showing the physician’s charges, the insurance company payment, and ‘adjustment’ amount.

All that aside, I believe that it is still in the best interest for clinics to have better customer service and patient communication. Be ready for those who have never had care, patients who have never had any procedures performed or those who simply want to know why their costs are ‘so high’ and other items are ‘not covered’.

A few weeks ago I was on the internet and came across a story about one of the last terrorist attacks. The feelings of sadness and uselessness still shock me, but just recently both personal and professional acts of ‘terrorism’ took me completely by surprise. Fed up and overwhelmed, this science geek did a little research and reached out to a trusted friend and psychiatrist who specializes in these problems within our communities….

Why is terrorism so powerful and impossible to eradicate?

It’s power comes both from the fact that anyone can commit terrorist acts with or without an army AND there is no way to stop it. But if that’s not scary or pessimistic enough for you, there is only one way to contain its viral nature since we cannot eradicate it.

In essence, terrorism is a choice. And choice is a freedom we fought for and cherish daily. Terrorism is also driven by an emotional act – one that gives the terrorist a reason or reason for their actions. Ironically, the ‘reasons’ for these acts are the key to stopping them.

Vengeance is the both the fuel and engine for this unstoppable hate machine. Couple this with a convincing leader with a personality disorder, a stressful environment, and promises of a better life for everyone and their families….. and now you have the ingredients to bake up an Adolf Hitler.

What makes terrorism today so frightening is that there really is no individual or group to fight and they use family and country not as a goal, but as their hypocritical fuel. ‘Victims’ whose family members were hurt or lost to the hate machine are the highest octane on the planet – one that mutates like a virus and then becomes a unique drug where the addict has no idea they are addicted.

Indeed, unstoppable. And that is the first step towards ‘the cure’. Individuals and society not only must want to put in the time and effort into understanding where the fuel comes from, but then agree unanimously and in unison to stop all terroristic actions. Lastly, and the hardest step is to keep it only in the history books with a hard, global no-tolerance agreement backed with a plan for its inevitable resurgence.

Sounds impossible, but a good start is to be more aware and open to conversations concerning this era. My optimistic version is that the world has been telling us where the problem lies for decades. Our families. All we have to do is listen. But really listen, then apply intelligent, constructive, solutions to both the toxic individuals, their harmful actions as well as the mundane, insidious ‘family environment’ situations as well.

All parents have challenges, some greater than others. In a perfect world, it starts with communication and ends with love.

If you’re not a narcissist, emotional terrorist or sociopath……

Dr Jung’s view of communication was via the unconscious mind using abstract imagery. Then, of course, there is your traditional counseling and other forms of psychological treatment. In my opinion, all good. Whatever works.

My individual style is to blend realistic transparency while dampening my anger with sarcasm using metaphors, similes, and movies. Yes movies, because like many successful business ventures, award winning and hit movies that connect with people do this by bonding with our emotions. That combined with my earlier rant about listening, the entertainment industry not only keeps their ear to the ground, but does so within many genres and venues. Then produces and promotes the ones that are going to be the most profitable. Not all, but some films (mostly from books or other media sources) weave stories within their production that move the audience and expose real life scenarios.

Your child may not understand what emotional terrorists or narcissists are nor the infinite forms that continue to exist in our world, but they can recite all the scenes of their favorite movies. Like a great song or impactful piece of art, if you can project the emotion and somehow blend it correctly with a real story, you can bet most of humanity has a direct connection or similar experience.

For example, Star Wars was produced well, casted well, and of course written well. There are other great movies that utilize “good” and “evil” for their emotional connection, but the “force” and “dark side” are brilliantly cloaked as powerful, intangible entities with colorful titles.

Where am I going with this? Darth Vader.

It’s easy to loath this guy in the first few series since he seems to robotically use his dark side power to destroy planets and hurt people. Your basic super villain. But as the series takes you to his child hood, it paints a different picture – one that encompasses a plethora of emotions and life experiences that all connect to family….

All the main powerful characters are connected to family and there’s always someone not only on the dark side, but constantly recruiting others to join. But the recruiting is done differently. The ‘force’ is simply bestowed upon those who have it and connect with a more harmonious culture. The ‘dark side’ is a place, culture, and group as well. You elect to join as an outcast from the force or after a disastrous event – one that produces a hateful emotional state and breaks your spirit or leaves you at ‘rock bottom’. The dark side is not only willing to accept these recruits and their anger, but they provide a place to validate their hateful actions and blame those within the force for their actions.

This new cult also gives a type of rationale or excuse for their emotionally corrupt condition….. As well as a group and environment to belong to – a new ‘family’. Bringing us full circle to the terrible stream of news stories and subsequent discussions that happen all over the world. Why do people continue to hurt their friends, family or co-workers? Or worse, those who can kill and somehow get off the hook?

In one of the series, Darth Vader is about to kill his son for not joining the dark side, but then ends up killing the dark leader in response to his son’s painful plea…. “I know there is good in you”. Now the entire audience is sobbing as “dad” dies in his son’s arms asking for forgiveness. Bam! Just like that, he’s a good guy.

And if that is not enough, the brilliant story goes back to his past hitting the emotional checklist below:

√ Top revenge emotion – He goes on a killing rampage to make them pay…

√ Ultimate sacrifice emotion -Then when he is about to lose the only love of his life, the dark side lord offers him a chance to save her life….. if he joins the dark side….

Booooo Yah! The best emotion of all – Validation. And even better, a Hollywood happy ending using validation as dessert with an added ‘to go’ order of Conflict.

Now they have the not so nice people in the audience who have done not so nice things in their lives to both their families and communities feeling pretty good about themselves – connecting them with this ‘victim’ and then validation for these actions. And at the same time, the honest, ethical and honorable families in the audience are conflicted. An equally ‘entertaining’ emotion connecting with both facts that killing and hurting people are still wrong, but feeling empathy for the killers and their ‘difficult’ pasts.

The validation-conflict connection is so significant, because it’s the emotional Hollywood engine that connects us with real life. And connects us without the painful reality of accountability or labeling. Narcissism is not a fun or attractive form of entertainment, nor popular conversation at happy hour, or anything your children want to chat about at the dinner table. The same goes for the more dangerous sociopath….. This personality disorder disconnects completely with others – no guilt, remorse, morals, or ethics. Those with this disorder and a drive to hurt or kill cannot be stopped nor respond to any deterrents. Thankfully, they are more rare than the NPD (Narcissist Personality Disorder), but can of course have narcissistic traits and vice versa…….

Is it the dry, psychological definition that makes these disorders so unpopular? Nope. To a degree we all have one or two narcissist symptoms when we look in the mirror. Nothing wrong with a little self-admiration here and there. But for those who meet the 5 or more symptom criteria for NPD, they see and react to a ‘house of mirrors’ – one that fuels their selfish acts and provides the rationale for their actions. For those outside this house of mirrors, even the entitlement or need for admiration can be ignored or excused from time to time. It’s the exploitation of others and lack of empathy where things go off the ethical rails.

But as we discussed earlier, it’s not the killing that anyone is disputing, it’s the ‘trigger’ and rationale behind it. And since it’s an easy, negative word to label someone with, the true narcissist can easily label his or her accuser as being one as well (see #2, 3, 4 and 7 below).

Narcissistic Personality Disorder

The hallmarks of NarcissisticPersonality Disorder (NPD) are grandiosity, a lack of empathy for other people, and a need for admiration. People with this condition are frequently described as arrogant, self-centered, manipulative, and demanding. They may also have grandiose fantasies and may be convinced that they deserve special treatment. These characteristics typically begin in early adulthood and must be consistently evident in multiple contexts, such as at work and in relationships.

People with NPD often try to associate with other people they believe are unique or gifted in some way, which can enhance their own self-esteem. They tend to seek excessive admiration and attention and have difficulty tolerating criticism or defeat.

Symptoms:

Individuals with Narcissistic Personality Disorder, according to the DSM-5, exhibit five or more of the following, which are present by early adulthood and across contexts:

3. Belief that one is special and can only be understood by or associate with special people or institutions

4. A need for excessive admiration

5. A sense of entitlement (to special treatment)

6. Exploitation of others

7. A lack of empathy

9. Arrogant, haughty behavior or attitudes

I wouldn’t say that our society embraces this personality, but they sure as hell do not do anything to make them accountable for deleterious actions. It’s the time and energy it takes to fight them that most of us do not have, but what’s worse is every attempt to right their wrongs does not stop their actions. Like the rise in violence at our children’s schools, the media and public recognition of these actions give them the platform they seek. In fact, simply engaging with them gives them validation as well as a platform to recruit more who are looking to cover up their actions and blame others as well. Unfortunately, many narcissists are quite successful, most likely due to the amount of energy they put into validation of their actions as well as a consistent preoccupation of power and money.

Emotional Terrorism is something I have not claimed as my own ‘discovery’ or entity that I have researched. Like most catchy phrases, I am sure it is out there somewhere. I am using it for personal reasons and hopefully clarity for a better understanding of this intangible enemy. I also believe this is the ugliness that truly forms the foundation of our family and community dysfunctions. If these immoral and selfish acts go unchecked, those who wield them will continue to use them within and outside their families.

Why not use others or your children to get what you want, then get them to buy in, join the culture, validate your actions, and keep your disciples from leaving the kingdom? Simple survival. And since it works, why would they stop? Especially since they have no ability to feel the pain and remorse their actions create.

And like a virus, these selfish acts get passed down to the next generation and accepted as tolerable. Or worse, the norm. And finally, when someone outside the culture poses a rational opposition, there is no law, deterrent, or penalty in place to help them. Frustration eventually causes the opposer to fight back without poise, sometimes lowering themselves verbally or physically to the emotional terrorist’s ‘level’….

And ta da! The lines where who started the process or whose “fault” it is get very blurry. Their well rehearsed, well crafted, and never ending game of “hot potato” where it’s always someone else’s fault wins every time due to the inevitable forfeit from those who see its futility.

Where it really gets ugly is the more serious Sociopath or ‘B’ personality disorders.

If they are genetic, nurtured, or created, these people have no conscience – completely detached from society and any reasons for their actions. And funny how this portion of the disorder’s definition gives the pathologic, dangerous sociopath a ‘reason’ for their condition. But ironically for this science geek, it is an odd type of relief that gives evilness a signature stamp. Hopefully, for our families, our communities and the rest of the world, our medical research, educational system, and political parties can work together to find a solution.

Will it come from a simple genetic alteration? Probably not, and the more aggressive attempts, like incarceration, death row, or war have all failed.

We simply cannot kill all the terrorists out there like weeds in our lawns. Nor can we give narcissists a whopping dose of narcissism or lock up all the sociopaths. Neither will care or even understand.

And not to get too deep into philosophy and the future, but this hopeful caretaker and medical research enthusiast believes that both the IT age and unstoppable data mining might be the cure.

Is transparency the answer to accountability? I feel that I have nothing to hide and to a degree do not mind law enforcement or the government keeping a distant eye on things. Knowing that terrorist attempts are stopped in this country (sometimes daily) without us knowing makes me and many others feel safe. But even if law enforcement or other ethical entities had this information or access to these resources, it won’t stop these communal, family, or even national atrocities from happening.

All we can do is lead by example, but this time do it with a hard edge. Like this transparent prose. Tomorrow is Father’s day and we all secretly want to be pampered and ‘recognized’ by our families. I would like to celebrate by recognizing those who continue to lead the ethical charge, have those uncomfortable conversations with their loved ones and pound that ‘do the right thing in times of stress and crisis’ stake deeper in the ground. If this blog clarifies or even creates some form of awareness for someone else, their family, community, or country blind to their misery or plight……then the time spent this morning was worth its weight in gold for this weary citizen. My dad is not with us anymore, but left behind a legacy of ‘working harder’ in times of crisis.

Thank you dad, I will pass this solid foundation on to my family and add a bidirectional layer of ‘working smarter’.

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I bumped into a friend of mine at the gym the other day and he asked about my ‘secret’. Devoid of ego, I’ve been asked everything from “what hormones are you taking” or “You must have a strict diet and good genes” to “Your weight training form needs work” or “That leg exercise is bad for your knees”.

The secret of feeling good, looking good and better health is a mental exercise. Just getting to the gym is the most popular, effective step, towards getting in shape. But working with and around others can be challenging. Working out at home or traveling have their problems as well like equipment limitations and designated areas with enough room.

Exercise is about as primitive and unconscious as survival and sex. One would think it is as automatic as it is inherent, but without the drive to hunt for food, what other reason do we have to work out?

The key is to find your connection with it – one that produces some type of an exertion euphoria, stress relief, daily achievement or simple joy. Then connect it with family and friends. I was fortunate to have a father who believed in getting up at dawn on the weekends and working in the yard until dinner time. Early in childhood, the activity provides a feeling of inclusion, fun, and accomplishment. Even during the rebellious teen age years, the initial complaining would fade and end up with the same family connection and feeling of accomplishment after a job well done.

The connection with friends with the same mind set came naturally with sports. Activity was as much as a lifestyle as it was an identity in high school. The best surprise was the ease and ‘fun’ felt at practice in comparison to those who whined before and during practice, then morned with thoughts about the next day’s work out. Who knew that simply repeating the hard work and stamina I learned at home on the field would produce the same recognition and feeling of accomplishment.

But something about the exertion, sweating, burning muscles stuck with me and became something I actually looked forward to feeling. They became more of a familiar sensation that dampens the usual negative response with the knowledge of positive outcomes that were on their way…. Now in my mid fifties, the joy has taken over since being able to work out becomes a blessing as well as a way to control health and longevity.

In my book, I tried to emphasize the importance of eating habits and the fact that it produces the best weight management outcomes. Weight training and aerobic exercise is the yin to the eating yang, but without the machine in which we exist and use to get from point A to B, eating takes a seat way at the back of the bus.

So I ask you. How do you find pure joy in your work outs? Walking with your grandchildren and doing a few curls with soup cans to firm up your arms? Power yoga with your wife, and a good protein meal after? Yard work with the kids, then taking them to roller skate? Or hitting the gym for a little alone time with a great 80s mix like yours truly…

Early man had to hunt and gather, but joy was probably not his/her main focus. Survival and seeing their family nourished was, but maybe that is also connecting with physical activity and a joyful outcome.

I tell our 12 year old before I run at the park, “I”m going out for the family kill. What do you want me to bring home?” This last christmas season, she told me to bring home a ‘snow pig’. She likes bacon for breakfast. I laughed before and during my run.

Over the last 20 years career, there have been major medical advancements in foot and ankle surgery. But in one arena, few things have changed.

When my heel pain patients come to the office, they are not only frustrated, but those painful first few steps in the morning have them or their spouses putting everything aside in their lives to make an appointment. Then sometimes cancelling….

Why? Because sometimes it goes away.

Why? Because in reality, it is an injury.

Plantar fasciitis is simply the band or the simile we us “bow string” like structure connecting the ball of your foot to the bottom of your heel (calcaneus bone).

So who cares, get to the point and where is my pill to make this all go away? Because 75% of our patients are cured and avoid surgery with a little education.

The foot is a simple machine made up of 26 bones that essentially ‘lock and unlock’ when standing and walking. This unlocking and dropping of the archway puts stress on the plantar fascia, unfortunately and must commonly where it connects to the bottom of the heel. The “heel spur” in reality is a calcification where the ligament attaches, not something that grows out of the heel and is responsible for that sharp pain in the morning. Its the pulling or micro ‘tears’ on the bottom of the heel combined with your entire body weight that causes the pain.

Then there is the other enigma. “After a few steps in the morning, it warms up and goes away” Not to get too scientific or deep into neurology, but the theory is that this is a evolutionary response to survive, cover up the pain and keep moving – or in the past, to get away from predators when injured. Repetitive pressure to the area can interrupt the pain signal to the brain temporarily. But with a short rest or sleeping all night, the distraction is gone and that first step sends that lovely, uninterrupted pain signal telling its homo sapien host – “me still injured”.

It’s a confusing paradigm because for most patients who have the mild to moderate variety (not seriously torn or a stress fracture) feel if they keep moving, they have less pain. But in reality, they are continuing to injure themselves by simply going to work or going out to get the mail.

We still give a mild cortisone injection that gives relief and has no side effects, but the main emphasis for this problem is to rest and hold the arch up when the essential weight bearing (like getting something to eat) is necessary. But rest is still the top priority. In professional sports, some players are using crutches to speed up recovery and healing time.

The good news for the rest of us is that enduring the pain and getting in to a better shoe with a higher heel (more weight on the ball of foot) or higher arch with ‘heel stabilizer’ like a running shoe can do the trick.

Arch supports can help as well, but for long term relief, orthotics are the holy grail. The problem is that not all orthotics are created equal, especially the custom molded variety. I have modified a traditional molding technique and better orthotic material that essentially cures 75% of my patients. Polypropylene is a thermo-molded, thin material that is also flexible to withstand activities like jogging or even high impact sports. Although we have several athletes using our device in their cleats and high top shoes, our female patients benefit the most since they can use these custom molded orthotics in their flats due their slim design.

Of course there is a surgery available for the remaining 25% of the patients who do not heal or have continued pain, but it’s becoming more and more rare. The procedure is quick with a small incision, sutures removed 2 weeks, full weight bearing in 3 weeks.

Interestingly, there is not that much pain associated with ankle problems. They usually present with aching and swelling at night, then stiffness in the morning that requires time to ‘warm up’. Unfortunately, there is usually a problem before these symptoms intensify and testing (x-ray and/or MRI) should be performed to rule out or in more severe problems.

In short, pain and/or stiffness in the morning are more connected to injury, old or new. Chronic swelling and aching at night is more connected “overuse syndrome”, arthritis, and/or other associated medical conditions.

If I had to say what the percentage of ankle patients who come in with these general complaints, it would be 80 to 90%. Ankle’s that ‘give out’ are also in this category, but the swelling, aching and stiffness symptoms top the charts.

The problem with these tolerable symptoms, is that even with mild pain or swelling, there could be more extensive damage inside of the joint. These patient histories range from major trauma like car accidents, ankle sprains and ankle fracturesto harsh worksite environments. And their timelines can span from weeks, to several months to decades.

So why are we able to get by with ibuprofen from time to time and get through our day?

We are designed to cover up pain with direct pressure or repetitive stimulus (walking and standing) all day. But all my ankle problem patients will tell you, they ache at night and “I feel like a 90 year old, hobbling to the bathroom in the morning… before it warms up a bit”.

The good news is that major surgery like Ankle Replacements or Ankle Fusions are no longer first in line. Proper testing (Radiograph, MRI, CT, Bone Scan) is imperative, but even a small cortisone injection can help patients with pain while ruling in or ruling out certain ‘internal’ ankle diagnoses. Custom orthotics are another conservative option for those who have foot and ankle alignment issues or foot pronation that cause or add to their ankle problem.

The Ankle Arthroscopic procedures are the absolute best first line of minimally invasive surgical treatment if conservative treatment fails. Studies show simply cleaning out debris or trimming partially detached cartilage will give patients pain relief, more ankle movement and better stability.

Warning: Minimally invasive procedure in the operating room setting

Another common problem encountered during these procedures is Subchondral Fracturing – a crushing or collapse of the bone just underneath the cartilage. This is vital to repair since this bone is what feeds the cartilage and keeps it alive.

Below is a short demonstration in the operating room showing the technique and application of this Calcium Phosphate product inside of the ankle joint.

And in addition to the bone repair are the next generation of biologics from Amniotic tissue (https://mimedx.com/amniofix/). This matrix works well mixed with saline, but better when mixed with PRP or bone marrow aspirate. Below is the an application for both enhancing ligament repairs and cartilage repair after an ankle arthroscope.

For more information or to find out more about your ankle problem, please feel free to log on to our website http://mfaspecialists.com/ or call 281-444-6800.